Provider Demographics
NPI:1679529762
Name:LACKEY, DIANE (SW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:LACKEY
Suffix:
Gender:F
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-4004
Mailing Address - Country:US
Mailing Address - Phone:215-925-2400
Mailing Address - Fax:
Practice Address - Street 1:1401 S 4TH ST
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19147-5907
Practice Address - Country:US
Practice Address - Phone:215-339-1079
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW003075104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker